Prehospital RSI

[kohlerrf]

Are you sure you don't have the midaz and etomidate reversed?!? Etomidate is a short acting sedative hypnotic that shouldn't be used for ongoing sedation. A better way to keep patients comfortable, but breathing on their own is a fentanyl infusion with just a touch of benzodiazepine PRN.

Nope ;-)

[Paramagic]

I rarely need anything more than Lidocane spray 10 of versed and a boogie to get the job done. and then an Etomidate chaser to keep them comfortably numb but breathing on their own. Practice the skill and do this skill and you will need the drugs less and less and that is good.

Except less drugs is not good when the purpose of those drugs is to both ensure optimal intubating conditions AND to minimize secondary brain injury, resulting in better functional outcomes from pre-hospital RSI in traumatic brain injuries, as demonstrated by Bernard et al.

And I have to second usalsfyre re: etomidate for ongoing sedation... huh?

[chbare]

Let us not forget the primary reason for RSI. Patients in the field are assumed to be non-fasting and at high risk for aspiration. The classical purpose for RSI is to prevent aspiration.

My take on RSI is cautious at best. Assuming we can somehow manage to educate people how to perform this produre safely with sound decision making, what happens after the intubation? Another thread here really demonstrates our general inability to manage patients post-intubation.

How many services have the tools and education to properly manage people post intubation?

[ERDoc]

ERdoc said it all. Most of all remember that intubation is a very simple skill. The problem and the bad press about it come from poor education and quality control. Although we have versed, Ativan, Valium, Etomidate,morphine and Sux all at our disposal I rarely need anything more than Lidocane spray 10 of versed and a boogie to get the job done. and then an Etomidate chaser to keep them comfortably numb but breathing on their own. Practice the skill and do this skill and you will need the drugs less and less and that is good. Lastly we use to use low and high dose Vec but Rock is a better substitute but frankly I would drop the Vec from your protocol in the first place and replace it with Sux.

I've got to agree with others, the Versed-Etomidate things seems backwards. Are you giving multiple doses of etomidate? Why not just use more versed once you have them tubed?

[firemedic37]

I have to chime in on this one. We have a great RSI protocol in my opinion, we use Etomidate then Vecuronim and continue sedation with Versed or Valium depending on provider preference. We have the option to give Fentanyl for pain if it is a traumatic or painful injury, usually if it is a medical patient there is little need for pain management. As several have already stated I would not use Etomidate for continued sedation.

Most importantly watch the patient and that will tell you if you need to provide more sedation or pain management for them. We rarely keep them paralyzed due to the fact the receiving hospitals don't want them to be since they can't check neurological status on arrival, however there are times when it is necessary to keep them safe.

As far as reversal agents, Narcan is safe to give however I caution the use of Romazicon. Even though we carry it, it is strictly a Medical Control ONLY medication due to the risks associated with it.

Hope this helps.

[mobey]

We have a great RSI protocol in my opinion,

we use Etomidate then Vecuronim and continue sedation with Versed or Valium depending on provider preference.

Etomidate and a long lasting paralytic? That is all?

What about Succ?

What if you miss the tube and cannot ventilate?

We have the option to give Fentanyl for pain if it is a traumatic or painful injury

Painful like having a steel blade inserted into your vallecula, or directly onto your delicate epiglottis, applying 8lbs+ of pressure, then placing a rigid tube in your airway and "choking" you from the inside with a air filled cuff?

usually if it is a medical patient there is little need for pain management.

Cite?

We rarely keep them paralyzed due to the fact the receiving hospitals don't want them to be since they can't check neurological status on arrival, however there are times when it is necessary to keep them safe.

You mean there are times when it is not necessary to keep them safe?

That is the poorest excuse not to paralyze a intubated patient I have ever heard. That is as bad as not treating abd pain so the Dr can assess.

Just how exactly do you check the neuro status on a patient sedated to the point of intubation and manual ventilation?

Are they just assessing reflex's? Isn't that something you can report?

Do you have to restrain these "neurologically intact" intubated patients?

[mobey]

If they're sick enough to need intubation from asthma or COPD, they're sick enough to break out the scalpel if you can't intubate them and a backup airway doesn't work.

Logic fail! (that may be my new favorite term)

*Rewrote*

If you have failed to provide a safe RSI/RSS for your patient, you may as well butcher thier airway to save thier life, and hand them off to someone more competent.

[ERDoc]

Etomidate and a long lasting paralytic? That is all?

What about Succ?

What if you miss the tube and cannot ventilate?

Painful like having a steel blade inserted into your vallecula, or directly onto your delicate epiglottis, applying 8lbs+ of pressure, then placing a rigid tube in your airway and "choking" you from the inside with a air filled cuff?

Cite?

You mean there are times when it is not necessary to keep them safe?

That is the poorest excuse not to paralyze a intubated patient I have ever heard. That is as bad as not treating abd pain so the Dr can assess.

Just how exactly do you check the neuro status on a patient sedated to the point of intubation and manual ventilation?

Are they just assessing reflex's? Isn't that something you can report?

Do you have to restrain these "neurologically intact" intubated patients?

If they are properly sedated there is no need for paralytics or heavy doses of pain meds. There is more than just simple reflexes that you can assess on a neuro exam when people are not paralyzed. Granted you will probably not need them in the field but in the ER and ICU they are helpful. Things such as corneal reflexes, ability to breathe on their own, cold calorics can help us to decide if they are salvageable or should be put on a terminal wean.

I agree that Vec isn't the best but some medical directors are not comfortable with Sux, so that is out of FM37's hands.

Edited October 5, 2011 by ERDoc

[HellsBells]

I think that the matter of whether or not to sustain paralysis with pts on vecuronium would be somewhat of a moot point, as it should last for the duration of most trips to the hospital.

[firemedic37]

If they are properly sedated there is no need for paralytics or heavy doses of pain meds. There is more than just simple reflexes that you can assess on a neuro exam when people are not paralyzed. Granted you will probably not need them in the field but in the ER and ICU they are helpful. Things such as corneal reflexes, ability to breathe on their own, cold calorics can help us to decide if they are salvageable or should be put on a terminal wean.

I agree that Vec isn't the best but some medical directors are not comfortable with Sux, so that is out of FM37's hands.

I knew there would be people that disagree with what I said, I felt that you answered it very well, thanks.

Removed duplicate quote.

Edited October 5, 2011 by firemedic37